SUBACUTE BACTERIAL

ENDOCARDITIS
and
ANTIMICROBIAL
PROPHYLAXIS

LCDR Marc E. Arena

Comprehensive
Dentistry
NPDS Bethesda, MD
The Root of All Evil
 Infective Endocarditis

Subacute Bacterial
Endocarditis
• microbial infection of
heart valves or
endocardium
• infective endarteritis
 Infective Endocarditis

Subacute Bacterial
Endocarditis
• 10-60 cases per
million people per
year
• 80% of cases from
patients with
predisposing
conditions
Infective Endocarditis

Causes
• Rapid onset-
Staphylococcus Aureus

• Insidious onset-
Streptococcus Viridans
Infective Endocarditis
SYMPTOMS
• Weakness
• Fatigue
• Weight loss
• Fever
• Chills
• Night sweats
• Anorexia
• Arthralgia
 Infective Endocarditis
SIGNS
• Petechial
Hemorrhages
• Linear Hemorrhages
• Osler Nodes
• Janeway Lesions
• Retinal Hemorrhages
• Heart Murmur
 Infective Endocarditis

Outcome
• Fatal 10-70% of cases
 Infective Endocarditis

Complications
• Reinfection
• Congestive heart failure
• Renal Disease
• Cerebral Vascular
Accident
Conspiracy Theories
Endocarditis and Dentistry
Dental procedures produce a transient
bacteremia:

Streptococcus Viridans
• S. Mutans
• S. Mitis
 Endocarditis and Dentistry
Risk of bacteremia from daily activities,
homecare & eating
1000 times greater than risk from dental
treatment
Streptococcus Viridans
• S. Mutans
• S. Mitis
 Endocarditis and Dentistry
Documentation
• Anecdotal evidence
• In vitro studies

Double blind placebo

study not likely
 Ideal Antimicrobial Prophylaxis
• Benefits outweigh risks
• Antibiotics in blood prior to bacterial
dissemination
• Loading dose
• Antibiotics specifically effective
• Antibiotics time specific
• Cheap and easy to use
Antimicrobial Recommendations

ADA/AHA (August 1997)

ADA/AAOS (July 1997)

 Indications for Prophylaxis
Cardiac Conditions
(table 1)
HIGH RISK
• Prosthetic heart valves
• Previous endocarditis
• Congenital heart
disease
• Pulmonary shunts
 Indications for Prophylaxis
Cardiac Conditions
(table 1)
MODERATE RISK
• Congenital cardiac
malformations
• Acquired valvar
dysfunction
• Hypertrophic
cardiomyopathy
• MVP with regurgitation
 Indications for Prophylaxis
OTHER CONDITIONS

• Rheumatic heart disease

• Systemic lupus
erythematosus
• Marfan’s Syndrome
• Prior history of drugs to
treat obesity
– Fenfluramine
– Phentermine
– Dex-fenfluramine
 Antimicrobial Prophylaxis
Not Recommended

Cardiac Conditions
• Isolated secundum atrial septal defect
• Repaired atrial septal defect, ventricular
septal defect or patent ductus arteriousus
• Previous CABG
• MVP without valvar regurgitation
 Antimicrobial Prophylaxis
Not Recommended

Cardiac Conditions
• Physiologic, functional or innocent heart murmurs
• Previous Kawasaki disease without valvar
dysfunction
• Previous Rheumatic fever without valvar
dysfunction
• Cardiac pacemakers and implanted defibrillators
 Antimicrobial Prophylaxis
Not Recommended

Other than Cardiac Conditions

• Neutropenic patient
• Diabetic patient
• Asplenic patient
• End stage renal disease
• Transplant patient
• HIV patient
 Antimicrobial Prophylaxis
Not Recommended

Other than Cardiac Conditions

• Total joint replacement (after two years)
• Other implanted devices
– Cerebrospinal fluid shunts
– Intravascular access device
– Penile implant
– Breast implants
– Intraocular implants
 Dental Procedures Associated
with Bacteremias
• Periodontal Procedures
– surgery
– scaling and root planing
– probing and recall maintenance
– subgingival placement of antibiotic fibers or
strips
– Prophylactic cleaning where bleeding is
anticipated
 Dental Procedures Associated
with Bacteremias
• Extractions
• Implant placement
• Reimplantation of avulsed teeth
• Endodontics beyond the apex
• Placement of orthodontic bands
• Intraligamentary injections
 Dental Procedures
NOT
Associated with Bacteremias
• Restorative dentistry
• Local anesthetic injections
• Intracanal endodontics and post placement
• Rubber dams
• Suture removal
 Dental Procedures
NOT
Associated with Bacteremias
• Removal of prosthodontic or orthodontic
appliances
• Oral impressions
• Fluoride treatments
• Radiographs
• Orthodontic appliance adjustment
• Shedding of primary teeth
 Antimicrobial Prophylaxis
Regimens
ADA/AHA
Standard general
prophylaxis:

• Amoxicillin • Adults: 2.0 grams;

Children: 50mg/kg
orally 1 hour before
procedure
 Antimicrobial Prophylaxis
Regimens
ADA/AHA
Unable to take oral
medications:

• Ampicillin • Adults: 2.0 grams IM

or IV; Children:
50mg/kg IM or IV
within 30 min before
procedure
 Antimicrobial Prophylaxis
Regimens
ADA/AHA
Allergic to penicillin:

• Clindamycin • Adults: 600mg;

Children: 20mg/kg
orally 1 hour before
procedure
 Antimicrobial Prophylaxis
Regimens
ADA/AHA
Allergic to penicillin:

• Cephalexin or
cefadroxil • Adults: 2.0 grams;
Children: 50mg/kg
*not recommended for use in orally 1 hour before
patients with immediate- procedure
type hypersensitivity to
PCN
 Antimicrobial Prophylaxis
Regimens
ADA/AHA
Allergic to penicillin:

• Azithromycin or • Adults: 500mg;

clarithromycin Children: 15mg/kg
orally 1 hour before
procedure
 Antimicrobial Prophylaxis
Regimens
ADA/AHA
Allergic to penicillin and
unable to take oral
medications:

• Clindamycin • Adults: 600mg;

Children: 20mg/kg IV
within 30 min before
the procedure
 Antimicrobial Prophylaxis
Regimens
ADA/AHA
Allergic to penicillin and
unable to take oral
medications:
• Cefazolin • Adults: 1.0gram;
Children: 25mg/kg IV
* not recommended in or IM within 30 min
patients with severe PCN before the procedure
allergy
 Antimicrobial Prophylaxis
Regimens
ADA/AAOS
Not allergic to penicillin
and able to take oral
medications:
• Cephalexin, • Adults: 2.0grams
cephradine or orally 1 hour before
amoxicillin the procedure
 Antimicrobial Prophylaxis
Regimens
ADA/AAOS
Not allergic to penicillin and
unable to take oral
medications: • Adults: 1.0gram IV or IM
• Cefazolin 1 hour before the
procedure
• Adults: 2.0grams IV or IM
• Ampicillin 1 hour before the
procedure
 Antimicrobial Prophylaxis
Regimens
ADA/AAOS
Allergic to penicillin and
able to take oral
medications:

• Clindamycin • Adults: 600mg orally 1

hour before the procedure
 Antimicrobial Prophylaxis
Regimens
ADA/AAOS
Allergic to penicillin and
unable to take oral
medications:

• Clindamycin • Adults: 600mg IV 1 hour

before the procedure
 Recommendations
• Screen all patients
• Excellent homecare
• Homecare mastered before routine
treatment
 Recommendations

• Expeditious treatment
• 7-14 days between appointments
 Recommendations

• Patients already taking antibiotics need a

different antibiotic
• Prerinse (not gingival irrigation)
• Edentulous patients
 Recommendations
If unexpected bleeding occurs
institute antibiotic prophylaxis
within 2 hours!
HAVE YOU SEEN THIS MAN?